Influence of selective phrasing on consent to DNAR

Within the framework of libertarian paternalism, nudges have been proposed as a way to guide decision-making while preserving individual autonomy, often by exploiting cognitive biases such as framing effects. Although nudges are commonly discussed as a promising means of promoting patients' best interests, their practical application in real medical contexts remains limited. This study examines whether physicians' selective phrasing, as a more direct form of intervention than conventional nudging, influences surrogates' decisions regarding "do not attempt resuscitation" (DNAR) orders.

We conducted a series of vignette-based online experiments in which participants evaluated hypothetical end-of-life scenarios. We tested whether subtle linguistic variations in physicians' explanations-such as mentioning potential harms of cardiopulmonary resuscitation (CPR) or associating DNAR with "naturalness"-affected participants' consent to DNAR.

Across studies, participants' willingness to consent to DNAR was significantly influenced by selective phrasing. Specifically, briefly highlighting the potential harms of CPR and framing DNAR as a form of "natural end-of-life care" were associated with higher rates of DNAR acceptance.

The findings demonstrate that physicians' language plays a crucial role in shaping end-of-life decisions without imposing explicit constraints on choice. This suggests that selective phrasing may function as a form of nudging in a broader sense, raising important ethical questions about the boundaries of permissible linguistic selectivity in medical communication.